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Jansson, Sven-Arne
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Jansson, S.-A., Backman, H., Andersson, M., Telg, G., Lindberg, A., Stridsman, C., . . . Rönmark, E. (2020). Severe asthma is related to high societal costs and decreased health related quality of life. Respiratory Medicine, 162, Article ID 105860.
Open this publication in new window or tab >>Severe asthma is related to high societal costs and decreased health related quality of life
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2020 (English)In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 162, article id 105860Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The aim of the present study was to estimate the societal costs and the key cost drivers for patients with severe asthma in Sweden. In addition, health-related quality of life (HRQOL) and morbidity of patients with severe asthma is described.

METHODS: The study population comprised adults with severe asthma recruited from a large asthma cohort within the Obstructive Lung Disease in Northern Sweden (OLIN) studies. During 2017, patients were interviewed quarterly over telephone regarding their resource utilization and productivity losses.

RESULTS: Estimated mean annual asthma-related costs per patient with severe asthma amounted to €6,500, of which approximately €2400 and €4100 were direct and indirect costs, respectively. The main cost drivers for direct costs were hospitalizations followed by drugs: approximately €1000 and €800, respectively. Patients on treatment with regular oral corticosteroids (OCS) had greater direct costs compared with those without regular OCS treatment. Co-morbid conditions were common and the costs were substantial also for co-morbid conditions, with a total cost of approximately €4200. The OCS group had significantly lower HRQOL compared to the non-OCS group.

CONCLUSIONS: The societal costs due to severe asthma were substantial. Costs for co-morbid conditions contributed substantially to both direct and indirect costs. The direct costs were significantly higher in the maintenance OCS-group compared to the non-maintenance OCS-group. These results indicate a need for improved management and treatment regimens for patients with severe asthma.

Place, publisher, year, edition, pages
Elsevier, 2020
Keywords
Costs, Health-related quality of life, Oral corticosteroids, Severe asthma
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-168152 (URN)10.1016/j.rmed.2019.105860 (DOI)32056670 (PubMedID)
Available from: 2020-02-18 Created: 2020-02-18 Last updated: 2020-02-20Bibliographically approved
Selberg, S., Hedman, L., Jansson, S.-A., Backman, H. & Stridsman, C. (2019). Asthma control and acute health care visits among young adults with asthma: A population-based study. Journal of Advanced Nursing, 75(12), 3525-3534
Open this publication in new window or tab >>Asthma control and acute health care visits among young adults with asthma: A population-based study
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2019 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 75, no 12, p. 3525-3534Article in journal (Refereed) Published
Abstract [en]

AIMS: To study asthma control and acute health care visits among young adults with asthma.

BACKGROUND: Despite the access to effective treatment and nursing interventions, poor asthma control is still common among individuals with asthma. However, studies describing clinical characteristics among young adults with asthma are rare.

DESIGN: A population-based cohort study.

METHODS: In 2015, as a part of the OLIN pediatric cohort I (recruited in 1996 at age 7-8yr), N=2291 young adults (27-28 yr) completed a postal questionnaire survey including questions on asthma and respiratory symptoms. Of these, N=280 (12%) were identified as having current asthma and were further studied.

RESULTS: Of those with current asthma, women reported respiratory symptoms and smoking to a greater extent than men. Approximately one-fourth had uncontrolled asthma and acute health care visits due to asthma was reported by 15% of women and 8% of men. Uncontrolled asthma was associated with smoking, lower educational level, use of reliever treatment most days and acute health care visits. Acute health care visits due to asthma were associated with periodic use of regular controller treatment also after adjustment for uncontrolled asthma.

CONCLUSION: The result indicate poor adherence to asthma treatment which may lead to decreased asthma control and acute health care visits.

IMPACT: Most young adults with asthma are diagnosed and treated in primary care, ideally in a team with a nurse. The main findings highlight the need for evidenced-based nursing interventions, contributing to a more efficient asthma management in primary care. This article is protected by copyright. All rights reserved.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
asthma, health services, nurses, nursing, patient care, primary healthcare, quantitative research, smoking, treatment adherence and compliance, young adult
National Category
Respiratory Medicine and Allergy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-162645 (URN)10.1111/jan.14174 (DOI)000486799500001 ()31441107 (PubMedID)2-s2.0-85074391870 (Scopus ID)
Available from: 2019-08-26 Created: 2019-08-26 Last updated: 2020-01-09Bibliographically approved
Backman, H., Jansson, S.-A., Stridsman, C., Eriksson, B., Hedman, L., Eklund, B.-M., . . . Rönmark, E. (2019). Severe asthma: A population study perspective. Clinical and Experimental Allergy, 49(6), 819-828
Open this publication in new window or tab >>Severe asthma: A population study perspective
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2019 (English)In: Clinical and Experimental Allergy, ISSN 0954-7894, E-ISSN 1365-2222, Vol. 49, no 6, p. 819-828Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Severe asthma is a considerable challenge for patients, health care professionals and society. Few studies have estimated the prevalence of severe asthma according to modern definitions of which none based on a population study.

OBJECTIVE: To describe characteristics and estimate the prevalence of severe asthma in a large adult population-based asthma cohort followed for 10-28 years.

METHODS: N=1006 subjects with asthma participated in a follow-up during 2012-14, when 830 (mean age 59y, 56% women) still had current asthma. Severe asthma was defined according to three internationally well-known criteria: the ATS workshop definition from 2000 used in the US Severe Asthma Research Program (SARP), the 2014 ATS/ERS Task force definition and the GINA 2017. All subjects with severe asthma according to any of these criteria were undergoing respiratory specialist care, and were also contacted by telephone to verify treatment adherence.

RESULTS: The prevalence of severe asthma according to the three definitions was 3.6% (US SARP), 4.8% (ERS/ATS Taskforce), and 6.1% (GINA) among subjects with current asthma. Although all were using high ICS doses and other maintenance treatment, >40% had uncontrolled asthma according to the asthma control test. Severe asthma was related to age >50 years, nasal polyposis, impaired lung function, sensitization to aspergillus, and tended to be more common in women. Further, neutrophils in blood significantly discriminated severe asthma from other asthma.

CONCLUSIONS AND CLINICAL RELEVANCE: Severe asthma differed significantly from other asthma in terms of demographic, clinical and inflammatory characteristics, results suggesting possibilities for improved treatment regimens of severe asthma. The prevalence of severe asthma in this asthma cohort was 4-6%, corresponding to approximately 0.5% of the general population.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
IgE, asthma, eosinophils, epidemiology, lung function, neutrophils
National Category
Public Health, Global Health, Social Medicine and Epidemiology Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-157380 (URN)10.1111/cea.13378 (DOI)000475694600009 ()30817038 (PubMedID)
Available from: 2019-03-18 Created: 2019-03-18 Last updated: 2019-09-09Bibliographically approved
Backman, H., Jansson, S.-A., Stridsman, C., Muellerova, H., Wurst, K., Hedman, L., . . . Rönmark, E. (2018). Chronic airway obstruction in a population-based adult asthma cohort: Prevalence, incidence and prognostic factors. Respiratory Medicine, 138, 115-122
Open this publication in new window or tab >>Chronic airway obstruction in a population-based adult asthma cohort: Prevalence, incidence and prognostic factors
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2018 (English)In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 138, p. 115-122Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Asthma and COPD may overlap (ACO) but information about incidence and risk factors are lacking. This study aimed to estimate prevalence, incidence and risk factors of chronic airway obstruction (CAO) in a population-based adult asthma cohort.

METHODS: /FVC<0.7.

RESULTS: decline and higher levels of neutrophils than asthma only. Smoking, older age and male sex were independently associated with increased risk for both prevalent and incident CAO, while obesity had a protective effect.

CONCLUSIONS: In this prospective adult asthma cohort, the majority did not develop CAO. Smoking, older age and male sex were risk factors for prevalent and incident CAO, similar to risk factors described for COPD in the general population.

Place, publisher, year, edition, pages
W.B. Saunders Ltd, 2018
Keywords
ACO, Asthma, Epidemiology, Longitudinal study, Risk factors
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-147915 (URN)10.1016/j.rmed.2018.03.036 (DOI)000432442400017 ()29724382 (PubMedID)2-s2.0-85045212522 (Scopus ID)
Available from: 2018-05-22 Created: 2018-05-22 Last updated: 2018-06-27Bibliographically approved
Backman, H., Hedman, L., Stridsman, C., Jansson, S.-A., Sandström, T., Lindberg, A., . . . Rönmark, E. (2018). Eosinophilic inflammation and lung function decline in a long-term follow-up of a large population-based asthma cohort. Paper presented at 28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE. European Respiratory Journal, 52
Open this publication in new window or tab >>Eosinophilic inflammation and lung function decline in a long-term follow-up of a large population-based asthma cohort
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2018 (English)In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 52Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

The relationship between lung function decline and airway inflammation among asthmatics has important therapeutic implications, but has rarely been studied in large samples or in population-based asthma cohorts.

A population-based adult asthma cohort (n=2055) was recruited during 1986-2001 and clinically examined including spirometry. In 2012-2014, all still eligible subjects (n=1425) were invited to a clinical follow-up including spirometry, blood sampling, and a structured interview, and n=1006 participated (55% women, mean age 59y, 32-92y). Linear regression was performed with age, sex, smoking habits, year of first examination, family history of asthma, socioeconomic status, eosinophils (EOS)>=0.3x109/L, and neutrophils (NEUT)>=5.0x109/L as independent variables and pre-bronchodilator FEV1 decline/year (ml and % of predicted [pp], respectively) as dependent. In secondary models, both ICS use at baseline and ICS use at follow-up were also included.

The mean annual FEV1 decline in ml (pp) among asthmatics with EOS<0.3, 0.4>EOS>=0.3 and EOS>=0.4x109/L, respectively, was 26ml (0.03pp), 29ml (0.10pp) and 34ml (0.27pp) (p<0.001). In adjusted analyses, EOS>=0.3 was significantly associated with FEV1 decline, both in terms of ml (4ml excess annual decline vs EOS<0.3) and pp. The association between EOS and FEV1 decline in pp, but not ml, remained when additionally adjusted for ICS use. The association with NEUT>=5.0x109/L was less clear.

On group level, adult asthmatics with higher levels of eosinophils in blood have a history of excess FEV1 decline compared to asthmatics with lower levels of eosinophil inflammation, independent of other factors such as ICS use.

Place, publisher, year, edition, pages
European Respiratory Society, 2018
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-155988 (URN)10.1183/13993003.congress-2018.OA294 (DOI)000455567100190 ()
Conference
28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE
Note

Supplement: 62

Meeting Abstract: OA294

Available from: 2019-02-07 Created: 2019-02-07 Last updated: 2019-02-07Bibliographically approved
Räisänen, P., Backman, H., Jansson, S.-A., Hedman, L., Stridsman, C., Lundback, B., . . . Rönmark, E. (2018). Male sex, younger age and smoking contribute to low participating rate in an epidemiological study of asthma and respiratory symptoms. Paper presented at 28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE. European Respiratory Journal, 52
Open this publication in new window or tab >>Male sex, younger age and smoking contribute to low participating rate in an epidemiological study of asthma and respiratory symptoms
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2018 (English)In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 52Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Background: High participation rate is warranted in order to ensure the validity in epidemiological study results. However, participation rates in population based studies have declined during the last decades.

Aim: To evaluate the causes and potential effects of non-response in a large population based survey about asthma and respiratory symptoms in Northern Sweden.

Methods: In 2016 a random sample of 12000 adults in ages 20-79 were invited to a postal questionnaire survey about asthma, rhinitis and respiratory symptoms. Three reminders were sent out. A random sample of 500 non-responders was identified for a telephone interview.

Results: The participation rate in the initial mailing was 40.6%, and 9.0%, 4.9%, and 2.6% in the subsequent reminders; in total 57.1% (n=6854) participated. Of the 500 non-responders, 320 were possible to reach and 272 participated in the interviews. The prevalence of respiratory symptoms did not differ significantly between responders and non-responders. Male sex, younger age, and smoking were associated with both late and non-response. Even if more subjects with asthma or allergic rhinitis were late and non-responders the prevalence estimates of these conditions were not substantially affected. However, 11.7% of participants and 18.0% of non-responders were smokers (p <0.001). Reasons for non-participation were mainly lack of time and having forgotten to answer.

Conclusion: With a response rate of 57.1%, our prevalence estimates of asthma and respiratory symptom were not biased while smoking was underestimated in this Swedish population.

Place, publisher, year, edition, pages
European Respiratory Society, 2018
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-155990 (URN)10.1183/13993003.congress-2018.PA1159 (DOI)000455567101228 ()
Conference
28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE
Note

Supplement: 62

Meeting Abstract: PA1159

Available from: 2019-02-07 Created: 2019-02-07 Last updated: 2019-02-07Bibliographically approved
Backman, H., Jansson, S.-A., Stridsman, C., Eriksson, B., Hedman, L., Eklund, B.-M., . . . Rönmark, E. (2018). Severe asthma among adults: Prevalence and clinical characteristics. Paper presented at 28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE. European Respiratory Journal, 52
Open this publication in new window or tab >>Severe asthma among adults: Prevalence and clinical characteristics
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2018 (English)In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 52Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Background: Severe asthma is a considerable challenge for patients, health care professionals and society. Few studies have estimated the prevalence of severe asthma according to modern definitions of which none based on a population study.

Methods: We estimated the prevalence and studied characteristics of severe asthma in a large adult population-based asthma cohort followed for 10-28 years in northern Sweden: 1006 subjects participated in a follow-up during 2012-14, when 830 (82.5%) still had current asthma (mean age 59y, 32-92y, 56% women). Severe asthma was defined according to three internationally well-known criteria: the US SARP, ATS/ERS and GINA. All subjects with severe asthma were undergoing respiratory specialist care, and were also contacted by telephone to verify adherence to treatment.

Results: The prevalence of severe asthma according to the three definitions was 3.6% (US SARP), 4.8% (ERS/ATS), and 6.1% (GINA) among subjects with current asthma. Although all were using high ICS doses and other maintenance treatment, >40% had uncontrolled asthma and <10% had controlled asthma according to the ACT. Severe asthma was related to age >50 years, nasal polyposis, decreased FEV1, not fully reversible airway obstruction, sensitization to aspergillus, elevated neutrophils and partly to eosinophils, and tended to be more common in women.

Conclusion: The prevalence of severe asthma in this asthma cohort was 4-6%, corresponding to approximately 0.5% of the population in northern Sweden. A substantial proportion of those with severe asthma had uncontrolled disease, and severe asthma differed significantly from other asthma in terms of both clinical and inflammatory characteristics.

Place, publisher, year, edition, pages
European Respiratory Society, 2018
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-156013 (URN)10.1183/13993003.congress-2018.PA3918 (DOI)000455567105052 ()
Conference
28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE
Note

Supplement: 62

Meeting Abstract: PA3918

Available from: 2019-02-01 Created: 2019-02-01 Last updated: 2019-02-01Bibliographically approved
Jansson, S.-A., Backman, H., Andersson, M., Telg, G., Lindberg, A., Eklund, B.-M., . . . Rönmark, E. (2018). Societal costs of severe asthma in Sweden. Paper presented at 28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE. European Respiratory Journal, 52
Open this publication in new window or tab >>Societal costs of severe asthma in Sweden
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2018 (English)In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 52Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Background: Severe asthma is a disabling and costly disease, often poorly controlled despite high-dosage controller medications.

Aims: We estimated societal costs from an adult severe asthma cohort, derived from a large-scale population survey in northern Sweden.

Methods: Severe asthma was defined by US SARP criteria, and high-dosage inhaled corticosteroids (ICS) were defined by GINA 2014 criteria. The study sample was identified from general population cohorts examined within the OLIN (Obstructive Lung Disease in Northern Sweden) studies (n=1,006). Patient reported asthma-related direct (outpatient care, medicines, hospitalisations) and indirect (sick leave, early retirement) resource consumption were collected by quarterly pre-defined telephone interviews during one year. Unit costs from 2017 were applied.

Results: In total, 32 patients with severe asthma (mean age 60.7y, 13 patients >65) were included. The mean annual total cost per patient was approximately €6,300. Two thirds of the costs (63%) was indirect costs (approximately €4,000). The main cost drivers in direct costs were hospitalisations and drugs: approximately €1,000 and €700, respectively. The main cost driver of indirect costs was productivity loss due to early retirement: €3,400. Patients who had received regular oral corticosteroid (OCS) treatment had greater costs compared with those without regular OCS treatment. In comparison with a previous Swedish study based on a sample of all asthmatics from the general population, a greater mean annual total cost per patient was observed.

Conclusions: In this severe asthma population in Sweden, societal costs were substantial. The results indicate a need for improved treatment regimens for patients with severe asthma.

Place, publisher, year, edition, pages
European Respiratory Society, 2018
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-155999 (URN)10.1183/13993003.congress-2018.PA1157 (DOI)000455567101226 ()
Conference
28th International Congress of the European-Respiratory-Society (ERS), SEP 15-19, 2018, Paris, FRANCE
Note

Supplement: 62

Meeting Abstract: PA1157

Available from: 2019-02-01 Created: 2019-02-01 Last updated: 2019-02-01Bibliographically approved
Backman, H., Hedman, L., Stridsman, C., Jansson, S.-A., Lindberg, A., Lundbäck, B. & Rönmark, E. (2017). A population-based cohort of adults with asthma: mortality and participation in a long-term follow-up. European Clinical Respiratory Journal, 4, Article ID 1334508.
Open this publication in new window or tab >>A population-based cohort of adults with asthma: mortality and participation in a long-term follow-up
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2017 (English)In: European Clinical Respiratory Journal, ISSN 2001-8525, Vol. 4, article id 1334508Article in journal (Refereed) Published
Abstract [en]

Background and objective: Asthma is a major public health concern. The aim of this study was to characterize a large population-based cohort of adults with asthma, and to study factors associated with all-cause mortality and non-participation in a long-term follow-up. Design: Random and stratified samples from five population-based cohorts were clinically examined during 1986-2001, and all subjects with asthma were included in the study (n = 2055, age 19-72 years, 55% women). Independent associations between different risk factors and (i) mortality and (ii) non-participation in a clinical follow-up in 2012-2014 were estimated. Results: In 1986-2001, 95% reported any wheeze and/or attacks of shortness of breath in the past 12 months, and/or asthma medication use. Over the up to 28 years of follow-up time, the cumulative mortality was 22.7%. Male gender, current smoking, and lower forced expiratory volume in 1 sec of predicted (FEV1% of predicted) were independent risk factors for mortality, while obesity was associated with non-participation in the follow-up. Older ages, ischemic heart disease, and low socioeconomic status were associated with both mortality and non-participation. Conclusions: The risk factors associated with mortality in this adult population-based asthma cohort were similar to those commonly identified in general population samples, i.e. male gender, current smoking, and lower FEV1% of predicted, while obesity was associated with non-participation in a long-term follow-up. Ischemic heart disease, low socioeconomic status, and older ages were associated with both mortality and non-participation.

Place, publisher, year, edition, pages
Taylor & Francis, 2017
Keywords
Public health, risk factors, natural history, obesity, ischemic heart disease, socioeconomic status
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:umu:diva-137633 (URN)10.1080/20018525.2017.1334508 (DOI)000403663400001 ()
Available from: 2017-07-18 Created: 2017-07-18 Last updated: 2018-06-09Bibliographically approved
Jansson, S.-A., Backman, H., Andersson, M., Telg, G., Lundbäck, B. & Rönmark, E. (2017). Health care consumption and HRQOL in severe asthma in Sweden. Paper presented at ISPOR 20th Annual European Congress, Glasgow, Scotland, November, 2017. Value in Health, 20(9), A513-A513
Open this publication in new window or tab >>Health care consumption and HRQOL in severe asthma in Sweden
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2017 (English)In: Value in Health, ISSN 1098-3015, E-ISSN 1524-4733, Vol. 20, no 9, p. A513-A513Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Objectives: Severe asthma is a disabling and costly disease, often poorly controlled despite high-dosage controller medications. The objectives of this analysis were to estimate health care consumption and to investigate health-related quality of life (HRQOL) in a severe asthma cohort, derived from a large-scale population survey in northern Sweden. Methods: Severe asthma was defined by US SARP criteria; high-dosage inhaled corticosteroids (ICS) by GINA 2014 criteria. In total, 32 patients with severe asthma were invited to a clinical examination and structured interview. Retrospective data of all asthma-related direct and indirect resource consumption during the last year were collected following a defined protocol. HRQOL was assessed by four patient-reported outcome measures: two general measures (SF-36; EQ-5D) and two disease-specific measures (SGRQ; ACT). The cohort was divided into two groups —patients with (OCS) or without maintenance oral corticosteroid (non-OCS) treatment. Results: Health care resource utilization was greater in the OCS-group compared with the non-OCS group. Mean annual number of visits to specialist care was 2.0 in the OCS group vs. 0.5 visits in the non-OCS group. Four patients in the OCS group had early retirement vs. none in the non-OCS group. HRQOL was worse in the OCS group, both when measured with general and disease-specific instruments. The Mental and Physical Component Summary scores of the SF-36 in the OCS vs. non-OCS group were 50.1 vs. 40.7 and 55.8 vs. 44.4, respectively. Similarly, the total SGRQ scores indicated worse HRQOL for the OCS-group compared with the non-OCS group (37.0 vs. 27.0). Conclusions: In this severe asthma population, patients treated with maintenance OCS consumed more health care resources, were more frequently early retired, and had worse HRQOL compared with those not receiving maintenance OCS. The results indicate a need for improved treatment for patients with severe asthma on maintenance OCS. Sponsor: AstraZeneca.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2017
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-143156 (URN)10.1016/j.jval.2017.08.645 (DOI)000413599901001 ()
Conference
ISPOR 20th Annual European Congress, Glasgow, Scotland, November, 2017
Available from: 2017-12-20 Created: 2017-12-20 Last updated: 2018-06-09Bibliographically approved
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